All addictive behaviors have at least these two things in common: (1) they help people cut off painful feelings and (2) they are strongly influenced or controlled by a destructive thought process. People who engage in drug or alcohol abuse, who have an eating disorder, or who compulsively work to the point of exhaustion are acting according to a pattern of negative thoughts or a critical inner voice (Firestone, Firestone, & Catlett, 2002). For example, the voice might say: “You need a hit so you can relax. You used again. You’re hopeless! You’ve already blown it, so you’d just as well have whatever you want.”

These behaviors represent a direct assault against their physical health and emotional well-being and restrict the ability to pursue important goals and priorities in life. Therefore, it is important that counselors help their clients identify the patterns of negative thinking that govern their addictive behaviors and challenge them to pursue more constructive ways of dealing with stress and emotional pain. These patterns make up what many clients refer to as the “negative voice in my head.”

What is voice therapy?
This article illustrates the application of voice therapy techniques to treating addicted clients. Data obtained during early studies using voice therapy (Firestone, 1988) led to hypotheses about the correlation between destructive thoughts and self-limiting, addictive and other self-destructive behaviors. Later, negative self-statements gathered during these early investigations were used to construct a scale to assess self-destructive potential and suicide intent (L. Firestone, 1991). The scale’s reliability and validity was established through research with more than 1,300 subjects that resulted in the development of the Firestone Assessment of Self-Destructive Thoughts (FAST) (Firestone & Firestone, 1996). Further research using this sample showed that scores on the FAST correlate significantly higher than the Beck Hopelessness Scale with subjects’ prior suicide attempts (Firestone & Firestone, 1998). Thus, empirical research has demonstrated the predictive power of the concept of the voice in suicide. The process also operates in reverse: when counselors become familiar with an individual’s dysfunctional behavior as contrasted with his or her stated goals and desires, they can also deduce the underlying voices.

In voice therapy, counselors help clients pinpoint environmental triggers that precipitate the painful emotions and negative thought patterns which, in turn, influence them to engage in addictive behaviors. In addition, by encouraging the pursuit of genuine wants, desires, and goals, counselors strengthen clients’ real selves, a process that enables them to achieve freedom from addictive, self-destructive behaviors.

Destructive thought process: “voice”
The voice has been defined as a systematic pattern of destructive thoughts, attitudes, and beliefs that are antagonistic toward the self and hostile toward others, and that strongly influence or control all forms of maladaptive behavior (Firestone, 1988, 1997a, 1998). The voice is not only made up of negative thoughts, it also includes feelings of anger, rage, or grief. It is not natural or harmonious, but is learned or imposed from without. The voice originates in childhood and represents the incorporation of parents’ negative traits, behaviors, and patterns of defense. The source of the critical inner voice seems to lie in an identification with, and imitation of, the methods by which one’s parents defended or numbed themselves. For example, if a client’s father drank when under stress it is likely that the client will adopt this particular method of relieving stress.

To varying degrees, all people suffer from internal conflict and a sense of alienation from themselves. On one hand, each individual has a point of view that reflects his or her natural wants, aspirations, and desires for affiliation with others, his or her drive to be sexual, to procreate, and to be creative. On the other hand, each individual has another point of view that reflects tendencies for self-limitation, self-destruction, and hostility toward other persons. This alien point of view is made up of a series of thoughts, antithetical toward self and cynical toward others, which we call the “voice.” It takes the form of an internal communication that ranges from minor self-criticisms to major self-attacks, and that sometimes includes suicidal ideation (Firestone, 1997b). The voice encourages self-soothing, addictive behaviors and promotes isolation, self-denial, self-destructive lifestyles, and at the extreme end, suicide.
Self-critical thoughts are sometimes experienced consciously, but more often than not they are only partially conscious or even totally unconscious. Many people are aware of having self-critical thoughts, but are generally unaware of how much they are living their lives according to the dictates of these thoughts.

The dual focus of the critical inner voice
The destructive voice that controls addictive behavior takes two contradictory forms. First it encourages the client to engage in the behavior and to indulge in his or her drug of choice. For example, clients who drink too much have reported that they often tell themselves things like, “You’ve had a rough week. You deserve to relax and have a drink.” They often act according to the urging of this voice and drink too much.

At this point, the destructive thoughts switch in their tone and become intensely punishing and angry, which makes it clear that the voice is not a conscience or a moral guilt — it plays both sides of the coin. The voice maliciously punishes the person for having engaged in the very behavior it had encouraged. “You weak-willed jerk. You said you weren’t going to drink anymore, and there you go, drinking again!”

After such a barrage of self-attacks, people feel worse and experience considerable emotional pain, turmoil, and distress. In this state, the critical voice is more likely to influence an individual to again engage in the addictive behavior to numb the pain, ease the agitation, or get rid of the upset feelings, which completes the cycle. “You’ve already broken your resolution, you’d just as well have another drink” (Firestone, Firestone, & Catlett, 2002).

It is clear that the process of listening to this type of punishing voice would not inspire clients to try to change their behavior in a positive direction. Hating oneself for a behavior and running oneself down never lead to constructive changes in behavior. People have strong tendencies to feel justified in attacking themselves because they “have the goods on themselves” so to speak; yet this self-attacking process is simply one part of the destructive cycle of addiction.

Voice therapy techniques
The methods of voice therapy were developed to bring destructive thoughts or voices to the surface, together with their accompanying emotions, so that clients could challenge them and change the behaviors that are regulated by them. Voice therapy was so named because it is a process of giving spoken words to negative thought patterns that govern people’s self-limiting, addictive, self-destructive behaviors (Firestone, 1997a).

Voice Therapy is a cognitive-affective-behavioral therapy. The emphasis on exposing negative thought processes in this methodology overlaps cognitive theories and therapies to a certain extent. However, the voice therapy approach is substantially different in that the methods deal more with the expression of feeling than analysis of logic or illogic. The expression of emotions that often accompanies the verbalization of the voice leads to unusual insights.

Steps in using voice therapy in the counseling process
When applied in a counseling situation, the technique of voice therapy consists of three steps: (I) the process of eliciting and identifying negative thought patterns, and releasing the accompanying emotions of anger and/or sadness; (II) discussing insights and reactions to verbalizing the voice; and (III) counteracting behaviors regulated by the voice through the collaborative planning and application of appropriate corrective experiences.

Step I. Identifying destructive thoughts
The principal technique of Voice Therapy consists of verbalizing negative thoughts in the second person format, as though someone else were speaking the thoughts: “You’re worthless and stupid” rather than “I feel like I’m a worthless person.” This particular format is important for two reasons: (1) this is the form in which most people think critically about themselves or experience internal dialogue (the voice is a kind of intrapsychic communication wherein people carry on silent conversations or dialogues with themselves as though another person were talking to them, advising, accusing, and enticing them in ways that are self-defeating and often self-destructive) and (2) this technique usually brings out considerable affect, leading to important emotional and intellectual insight.

When clients put their thoughts in this form, strong feelings often emerge in which the tone is transformed from flat, matter-of-fact statements to a more expressive, emotional verbalization. The counselor can offer encouragement with statements like, “Say it louder,” “Don’t hold back,” or “Try to let go.” Expressing the voice in this format facilitates the process of separating the client’s own point of view from alien, hostile thoughts internalized during his or her formative years.

Step II. Discussing insights and reactions to verbalizing the voice
After clients have verbalized the voice and expressed the accompanying feelings, the counselor can help them identify the dysfunctional core beliefs that govern their lives and that provide rationalizations for their self-defeating and self-destructive behavior. Often, these beliefs emerge as clients express the anger and sadness associated with the verbalization of the voice.

In addition, they frequently develop insight spontaneously into the origin of their negative thought processes. At this point, through sensitive questions, clients can be encouraged to identify the connection between their destructive thoughts and important events in their present-day lives. They can also explore the relationship between their self-attacks and the types of behaviors that they dislike in themselves.

Step III. Collaborative planning of corrective experiences
In this phase of the counseling process, client and counselor attempt to interrupt addictive behavior patterns through collaborative planning and suggestions for behavioral change that correspond to each client’s special interests, wants, and motivations. Plans for behavioral change generally fall into two categories: (a) corrective suggestions to help control addictive habit patterns and (b) corrective suggestions that expand the client’s world by encouraging him or her to gradually overcome fears related to pursuing wants and goals.

Corrective suggestions for behavioral change in the voice therapy model are different from those used in behavioral or cognitive-behavioral therapies in that they are derived from the types of negative thoughts the client has discovered for him or herself. The ideas are not strategies imposed by the therapist, but are usually initiated by clients after they have identified the destructive thoughts controlling the specific addictive behavior they want to change. The motivation for trying to change addictive behaviors comes from the client, who envisions new behaviors and activities as an “answer” to the dictates of his or her voice.

Journaling as an adjunct to counseling
Maintaining a daily journal can be an important adjunct to counseling because it helps clients identify specific events that precipitate a self-attacking thought process (Firestone, 2001). When clients write down the thoughts that induce them to engage in an addictive behavior, they are better able to resist the temptation to indulge in their drug of choice.

Specific journal format
The authors have developed a specific formal for journaling that has been adapted for use by clients trying to break an addictive pattern of behavior. On the left-hand side of a page, clients record the destructive thoughts that are seducing them to indulge and the voices that are then punishing them for indulging. In the middle column, they record the feelings that these diverse voices arouse in them. In the right-hand column, they write a more realistic and congenial point of view. In recording their more rational thoughts, clients are encouraged to express a more compassionate and realistic view of themselves, their qualities, and their reactions to giving up their addiction (Firestone, Firestone, & Catlett, 2002).

Voice therapy in substance abuse treatment
Perhaps the most simple and straightforward examples of the use of corrective suggestions are those that relate to substance abuse. Implementing a suggestion that breaks a self-soothing, tension-reducing habit pattern is often a first step toward change. Although it is difficult for the alcoholic, heavy drug user, or eating disordered client to maintain the resolution to alter his or her addictive patterns throughout the course of treatment, it is necessary for a successful prognosis. In spite of this dilemma, a counselor of strong character, concerned and sensitive, can establish a preliminary contract with the client on this issue and act as a “transitional object” to alleviate the anxiety aroused by giving up the addiction. Counselors need to approach the collaborative effort of planning corrective experiences with compassion and a nonjudgmental attitude, particularly in those cases where clients may indicate that they are not quite ready to undertake basic changes or stop an addiction.

Early in treatment, the counselor can point out, in nonjudgmental terms, the serious consequences of the client’s addiction. It is important that clients NOT relate to their behavior as a moral issue, but that they become aware, on a feeling level, of the harm they are inflicting on themselves through the continued use of substances. The therapist’s warmth, empathy and maturity are essential in gaining and holding the client’s respect and trust so that they will continue to be motivated to give up the addiction. Controlling addictive behavior leaves clients vulnerable to the painful feelings they have been suppressing often since childhood, yet it opens the way for potential cure.

Recognizing environmental triggers
Recovering addicts report that it was important for them to identify their triggers, that is, the specific cues in the environment that increased their urge to use drugs or alcohol. Many previous drug users disclosed that when they were with friends who also used, they felt the pull to indulge their habit. Others mentioned isolation as being a powerful trigger. When they had empty time that left them feeling alone with their feelings, destructive thoughts and angry feelings usually emerged. For this reason, the authors believe that it is important for clients to think about the events or situations in their everyday lives when they feel the most tempted to use their drug of choice.

On the left-hand side of the page, clients write down the situations and social interactions that trigger the critical inner voices experienced during the cycle of addiction described above. In the middle column, they record the thoughts they are experiencing at the time, the seemingly positive or seductive thoughts prior to using as well as the vicious, punishing thoughts that emerge afterwards. On the right-hand side of the page, they record their more realistic, compassionate point of view. In many cases, it is worthwhile for clients to write a narrative about their life or compose a personal history. In this history, they describe the events in childhood that they think may have influenced them to turn to self-nurturing, self-soothing behaviors to dull their pain and relieve their frustration. In constructing a personal narrative, clients come to understand why they became addicted and learn that they did the best they could under the circumstances to survive, both physically and psychologically (Firestone, Firestone, & Catlett, 2002).

Psychological factors of addiction development
The use of substances, including alcohol, drugs and food, to satisfy oneself is closely related to oral deprivation, faulty parenting, illness, and loss during an individual’s formative years. When infants and children suffer unusual frustration and deprivation, they resort to compensatory self-nurturing, self-soothing behaviors, such as thumb-sucking or rubbing a favorite blanket. As adults, they continue to attempt to comfort themselves and relieve their own tension using more sophisticated means, for example, drugs, alcohol, food, excessive TV watching, video games, compulsive overwork, etc. In every case, the addiction supports a posture of false independence, an illusion that they are totally self-sufficient and have no need of other people. It is extremely difficult to break these patterns, because the anxiety alleviated by the use of substances comes to the surface during withdrawal, leaving the client in a state of disorientation and helplessness. There are painful emotions of sadness, anger or rage that are complicated by childlike, dependent behaviors when clients attempt to abstain from the use of these substances (Firestone, 1997a).

Strengthening the real self
Just as the voice conceals the client’s real self, addictions serve to cover over and keep their real feelings at bay. As people give up behaviors dictated by the voice, their real self — the core of their personality — increasingly emerges and takes precedence over the enemy within. An individual’s real self is made up of his or her wants, desires, and special goals. As people relinquish addictive behavior and begin to regain the vast array of feelings they have been suppressing for years, they become more aware of the wants and desires that are a fundamental part of their unique identity.

However, many clients still believe on a deep level that they cannot face the painful feelings they suppressed while growing up. They are often hesitant about giving up self-soothing habit patterns that have helped numb their pain and dull their anxiety. It may sometimes seem easier to soothe their pain or gratify their own wants with alcohol, drugs, or food rather than to endure the intense longing and wanting they experienced as children, when their real needs were not met. Relinquishing an addiction may result in feelings of helplessness and dependence. It is not until a client has an experience in their adult lives where they are able to successfully face the frustrations of their wants and desires that they learn, on an emotional level, that they can no longer be hurt as they were in childhood.

Regardless of the specific techniques, clients must become aware of their needs and desires and use the counseling situation to ask directly for what they want. The limits to personal gratification inherent in the discipline of the counseling relationship lead to frustration of clients’ needs, which are generally based on the needs that were frustrated during their formative years. Clients learn to survive without the counselor’s “parental support,” and come to terms with their anger at being frustrated. This is the crux of lasting therapeutic change in addicted individuals, because in facing their anger at the inevitable frustration, they strengthen their real self and relinquish their dependency on pain-relieving substances. Recognition that the needs they experienced as children are no longer vital to their adult happiness helps addicted clients expand their boundaries and get more enjoyment out of life.

A process of “coming to terms”
The authors have concluded that all clients, indeed all people, suffer from some degree of addiction that interferes with their living fully (Firestone, 1993). The primary goal of our therapy has been to help people come to terms with the painful feelings and frustrations that caused them to revert to the use of addictive substances. When clients are willing to take a chance and sweat through the anxiety and fear aroused when they give up these addictions, they find that they are living with dignity and self-respect, and are coping more effectively with the stresses of everyday life.

Lisa Firestone, PhD, is Director of Research and Education with the Glendon Association. She is an active conference presenter, practicing psychologist and co-author of Conquer Your Critical Inner Voice and Creating a Life of Meaning and Compassion: The Wisdom of Psychotherapy.

Joyce Catlett, MA, is co-author of Creating a Life of Meaning and Compassion: The Wisdom of Psychotherapy, Fear of Intimacy, and Conquer Your Critical Inner Voice, among others. She has co-produced more than 30 video documentaries on mental health issues.

For more information about Voice Therapy, contact The Glendon Association at 800-663-5281 or visit www.glendon.org.

References
Firestone, L. (1991). The Firestone Voice Scale for Self-Destructive Behavior: Investigating the scale’s validity and reliability. (Doctoral Dissertation, California School of Professional Psychology, 1991) Dissertation Abstracts International, 52, 3338B.
Firestone, R.W. (1988). Voice therapy: A psychotherapeutic approach to self-destructive behavior. Santa Barbara, CA: Glendon Association.
Firestone, R.W. (1993). The psychodynamics of fantasy, addiction, and addictive attachments. American Journal of Psychoanalysis, 53, 335-352.
Firestone, R.W. (1997a). Combating destructive thought processes: Voice Therapy and separation theory. Thousand Oaks, CA: Sage.
Firestone, R.W. (1997b). Suicide and the inner voice: Risk assessment, treatment, and case management. Thousand Oaks, CA: Sage.
Firestone, R.W. (1998). Voice Therapy. In H.G. Rosenthal (Ed.), Favorite counseling and therapy techniques: 51 therapists share their most creative strategies (pp. 82-85). Washington, DC: Accelerated Development.
Firestone, R.W. (2001). Behavioral assignments for individual and couples therapy: Corrective suggestions for behavioral change. In H.G. Rosenthal (Ed.), Favorite counseling and therapy homework assignments: Leading therapists share their most creative strategies (pp. 85-90). Philadelphia, PA: Brunner-Routledge.
Firestone, R.W. & Firestone, L. (1996). Firestone Assessment of Self-Destructive Thoughts. The Glendon Association.
Firestone, R.W. & Firestone, L. (1998). Voices in suicide: The relationship between self-destructive thought processes, maladaptive behavior, and self-destructive manifestations. Death Studies, 22, 411-443.
Firestone, R.W., Firestone, L., & Catlett, J. (2002). Conquer your critical inner voice: A revolutionary program to counter negative thoughts and live free from imagined limitation. Oakland, CA: New Harbinger Publications
Hammil, P., (1994). A drinking life: A memoir. Boston: Little, Brown and Company.

This article is published in Counselor,The Magazine for Addiction Professionals, October 2004, v.5, n.5, pp. 49-55.

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